Clinical documentation improvement (CDI) consultant and HIM educator Lisa Campbell, PhD, CDIP, CCS, CCS-P, started working with one of her most important clients after the CEO of a Midwestern medical group noticed her studying an AHIMA CDI textbook while she was getting some work done at her local Starbucks.

The CEO sitting near her asked her what CDI was. When she explained how it works he said, “We need you.”

In her presentation “CDI in the Physician Office Setting: A CDIP Shares a Physician Office Journey and Success” at AHIMA’s CDI Summit on Monday morning, Campbell talks about how CDI guidance helped a multi-specialty clinic with 80 providers dramatically improve their coding accuracy and reimbursement levels.

Documentation Wake-up Call

When Campbell was brought onsite in the clinic of the CEO she met at Starbucks she performed a documentation analysis that included evaluation of: evaluation and management leveling, diagnosis accuracy, medical necessity charge capture, quality of care, and meaningful use progress. In her first assessment in March 2015, 70 providers in the practice had coding accuracy levels at 59 percent and above. Only five providers had accuracy rates between 60 and 65 percent.

Shortly after that initial assessment the medical group decided to deploy CDI in the outpatient setting. To help them launch it, Campbell did the records analysis and then met with the CEO, key stakeholders, the electronic health record (EHR) coordinator, and others for one-hour interviews.

“So many people said ‘I don’t want to be audited’ and I’d say “This is isn’t an audit it’s documentation improvement,” Campbell said. She started to hear fears about an audit so frequently that she started wearing a pin on her shirt that said “documentation improvement.”

Campbell started to slowly tackle the documentation problems by hosting roundtables, lunch and learns, and even shadowed physicians while they saw patients in the office. She quickly learned that many physicians consistently “cloned,” or copy and pasted, note after note after note, across multiple patients.

This led to significant errors in patient records.

“A lot of young men I saw had menstrual periods, a lot of female patients had ‘normal scrotums,’” because notes were cloned so sloppily, Campbell said.

Campbell also helped the staff prepare for ICD-10-CM/PCS implementation, and admits that she was very angry with the Centers for Medicare and Medicaid Services (CMS) for instituting the grace period—the year-long period when CMS accepted certain unspecified codes to ease the ICD-10 transition after October 1, 2015. Instead, Campbell made sure that claims were coded to the most accurate level of specificity, ignoring the grace period entirely.

By the end of her stint with the medical group coding and documentation accuracy levels soared. By September 2015, 10 providers maintained accuracy rates between 90 and 100 percent; 25 providers attained accuracy levels between 80 and 89 percent, and only 14 providers achieved 59 percent and below accuracy levels. The CDI program was such a success that the group hired a full-time CDIP specialist.

“As a consultant one thing I realized is that I might have lost money on this project but gained a lot of experience and a client for life,” Campbell said.